The nurse has received SBAR report for their four assigned patients on a cardiac unit. Which patient will the nurse prioritize to assess first?

The patient newly diagnosed with heart failure whose pulse oximetry is 94% on 2L oxygen.

A patient scheduled for echocardiogram who has altered level of consciousness and restlessness.

The patient who has dyspnea on exertion but wants to be discharged against medical advice.

The patient whose ejection fraction (EF) is 50% and has 2+ bilateral lower extremity edema.

Answer and Explanation

The Correct Answer is B

Choice A reason: The patient with heart failure whose pulse oximetry is 94% on 2L oxygen is stable at the moment. While they require monitoring, they do not take immediate priority over the patient with altered consciousness.

Choice B reason: Altered level of consciousness and restlessness are critical symptoms that require immediate assessment. These could indicate a life-threatening condition such as hypoxia, electrolyte imbalance, or stroke, necessitating prompt evaluation and intervention.

Choice C reason: The patient with dyspnea on exertion who wants to be discharged against medical advice is important, but altered consciousness takes precedence due to its potential severity.

Choice D reason: The patient with an ejection fraction of 50% and 2+ bilateral lower extremity edema is stable and does not require immediate intervention compared to the patient with altered consciousness.

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Correct Answer is D

Explanation

Choice A reason: Family history of common bile duct disorder is not a known trigger for irritable bowel syndrome (IBS). IBS is a functional gastrointestinal disorder with multifactorial causes, including but not limited to genetics, gut-brain axis, and environmental factors. Bile duct disorders and IBS have different pathophysiological mechanisms and are not directly linked.

Choice B reason: The frequent occurrence of blood in the stool is not a cause of IBS. Blood in the stool is more indicative of other gastrointestinal conditions such as inflammatory bowel disease (IBD), colorectal cancer, or haemorrhoids. IBS is characterized by abdominal pain, bloating, and changes in bowel habits without organic pathology such as bleeding.

Choice C reason: While there is some evidence suggesting that individuals with a family history of psychiatric disorders and food allergies may have a higher prevalence of IBS, it is not the main cause. These factors may contribute to the onset and exacerbation of symptoms but are part of a broader spectrum of triggers, including genetics, stress, and gut microbiota.

Choice D reason: Environmental and psychosocial factors are indeed associated with the onset of IBS. Factors such as stress, anxiety, depression, and traumatic life events can play a significant role in the development and exacerbation of IBS symptoms. Additionally, environmental factors like diet, infections, and changes in gut microbiota are known to influence IBS. This choice aligns with current evidence-based understanding of the condition.

A. Fruity-smelling breath B. Sweating and nervousness C. Nausea and vomiting D. Increased thirst and urination

Correct Answer is B

Explanation

Choice A reason: Fruity-smelling breath is a symptom of ketoacidosis, not hypoglycemia. Ketoacidosis occurs when the body produces high levels of ketones due to a lack of insulin, leading to metabolic acidosis.

Choice B reason: Sweating and nervousness are common symptoms of hypoglycemia. Low blood glucose levels trigger the release of adrenaline, which causes these symptoms. Patients should check their blood glucose when experiencing these signs to prevent severe hypoglycemia.

Choice C reason: Nausea and vomiting are more associated with ketoacidosis. High blood glucose levels and the presence of ketones can cause gastrointestinal upset.

Choice D reason: Increased thirst and urination are also symptoms of hyperglycemia and ketoacidosis. These symptoms result from the body's attempt to eliminate excess glucose and ketones through urine.

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The nurse has received SBAR report for their four assigned patients on a cardiac unit. Which patient will the nurse prioritize to assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a new diagnosis of irritable bowel syndrome (IBS). The patient is upset and concerned about how they got IBS. What evidence-based information, related to the causes of IBS, will the nurse provide to this patient?

Correct Answer is D

Explanation

The nurse is teaching a patient with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. The patient demonstrates understanding of hypoglycemia by stating they will check their blood glucose when experiencing which of the following symptoms?

Correct Answer is B

Explanation

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